The Insiders as Outsiders: Professionals Caring for an Aging Parent.

As professionals in geriatric medicine and social work, we are caregivers for our widowed mother of 90 years, a woman with neurocognitive disorder and multiple medical conditions. She has had repeated, problematic encounters with the health care system over the past 4 years. Caring successfully for an aging parent requires a comprehensive understanding of her unique medical, psychological, and functional status; need for social support; and overall goals of care. Poor communication between and among clinical teams-and with patients and families-is ubiquitous. The patient and family are not consistently listened to, or integrated, into the clinical team. We recount our experiences of one hospitalization and how we addressed the recurring obstacles we faced. Our training and experience gave us a firm understanding of the hazards of hospitalizing an elderly person and the need to be present, engaged, attentive, active, and vigilant. We caught and corrected major mistakes: failure to follow-up abnormal test results, multiple medication errors, undertreatment of pain, poor fall prevention, and inappropriate assessment and placement for rehabilitation. In a dysfunctional health care system, the family is, and must be, the ultimate fail-safe mechanism. We identify potentially effective solutions for the problems we encountered: adoption of dementia-sensitive and patient- and family-centered care, improved communication, better management of information (including better systems for monitoring lab results and for dispensing and reconciling medications), expediting care, changing reimbursement and regulation, and improving discharge planning and placement.

A competency-based medical student curriculum: taking the medication history in older adults.

Older adults are the largest consumers of prescription medications. Taking multiple medications, which interact with medical, psychological, and socioeconomic factors, increases a person's risk of nonadherence and adverse events. A curriculum was developed to train medical students to identify these risks and make recommendations for improving medication safety. The curriculum, consisting of a self-study computer tutorial, a small-group simulated-patient (SP) experience, and an online competency assessment, was implemented in the students' second year of training. Groups (N = 28) of five to seven students interviewed the SP and were assessed on their ability to identify medication concerns (N = 18) and make recommendations (N = 18) on improving medication safety. On average, student groups identified 16.1 concerns and made 15.4 recommendations. On the competency assessment several months later, students were given a case scenario and again asked to identify concerns (N = 7) and make recommendations (N = 7). Students (N = 176) were required to achieve a preset performance standard on the assessment. A high percentage (97.2%) of students achieved the standard (a score of 8/14) on their first attempt; the remainder achieved the standard on their second attempt. Student evaluations indicated high levels of satisfaction with the curriculum. The learning objectives, competency assessment, and instructional activities were closely aligned. Instructional activities provided students with an opportunity to practice the competency in a nonthreatening environment. The SP session materials are available through MedEdPORTAL and can readily be incorporated by other institutions into existing curricula.

A competency-based medical student curriculum targeting key geriatric syndromes.

The University of Miami Miller School of Medicine (UMMSM) has developed and implemented a competency-based undergraduate medical education (UME) curriculum that targets 61 learning objectives for three geriatric syndromes: dementia, falls, and delirium. This curriculum redesign changed the educational focus from what is taught to what is learned. Students complete 13 different competency assessments throughout their four years of training and are required to meet specific performance standards. Documentation of competency is now provided for 600 students annually. This paper describes the design, development, implementation, and evaluation of this curriculum, reviews our data-driven curriculum quality improvement efforts, and discusses the challenges to translating student competency into routine practice.

Atypical antipsychotics for the treatment of delirious elders.

BACKGROUND: Delirium occurs frequently in hospitalized patients and is reported to occur at a rate of 10% to 40% in hospitalized elderly patients. The gold standard of treatment is to treat the underlying cause of delirium and use high-potency antipsychotics such as haloperidol to target the behavioral disturbances. Since the development of atypical antipsychotics, many psychiatric conditions that were previously only treatable using high-potency antipsychotics may now be managed with the atypical agents. This review will examine the current literature on atypical antipsychotics and summarize the results from published trials in order to evaluate the efficacy and potential benefits of atypical antipsychotics for the treatment of delirium in the elderly population. METHODS: A search of the published literature was conducted using MEDLINE and PubMed. The PubMed search was limited to articles that were (1) written in the English language, (2) focused on human subjects above age 65, and (3) were in the format of review articles, randomized controlled trials (RCTs), clinical trials, or meta-analyses. The initial PubMed search was conducted in March 2006 with follow-up investigations in April 2006 and July 2007. RESULTS: Risperidone, the most thoroughly studied atypical antipsychotic, was found to be approximately 80% to 85% effective in treating the behavioral disturbances of delirium at a dosage of 0.5 to 4 mg daily. Studies of olanzapine indicated that it was approximately 70% to 76% effective in treating delirium at doses of 2.5 to 11.6 mg daily. Very few studies have been conducted using quetiapine; it also appears to be a safe and effective alternative to high-potency antipsychotics. In comparison to haloperidol, the frequency of adverse reactions and side effects was found to be much lower with the use of atypical antipsychotic medications. In the limited number of trials comparing atypical antipsychotics to haloperidol, haloperidol consistently produced a higher rate (an additional 10% to 13%) of extrapyramidal side effects. CONCLUSIONS: A review of current literature supports the conclusion that atypical antipsychotic medications demonstrate similar rates of efficacy as haloperidol for the treatment of delirium in the elderly patient, with a lower rate of extrapyramidal side effects. There is limited evidence of true efficacy, since no double-blind placebo trials exist.

Therapeutic failure-related hospitalisations in the frail elderly.

BACKGROUND AND OBJECTIVE: Although therapeutic failure may be a common cause of drug-related morbidity in older adults, few studies have focused on this problem. The study objective was to determine the frequency and types of, and the factors associated with, therapeutic failure leading to hospitalisation in frail, elderly patients, using a new instrument named the Therapeutic Failure Questionnaire (TFQ). METHODS: The sample included 106 frail, hospitalised elderly patients enrolled in a 1-year-long health service intervention trial at 11 Veterans Affairs Medical Centres. The TFQ was developed by a team of clinical geriatricians and tested for reliability by two clinical pharmacists and a geriatrician on a sample of 32 patients. To establish validity, a geriatrician retrospectively reviewed the computerised medication records and clinical charts for these patients and applied the TFQ to determine probable therapeutic failures at the time of hospital admission. RESULTS: Inter- and intra-rater reliability for the TFQ were very good (kappa = 0.82 for both). Overall, 11% of patients had one or more probable therapeutic failures (TFQ scores between 4 and 7) leading to hospitalisation. Cardiopulmonary disease was a common 'indicator' of therapeutic failure and was often the result of non-adherence. The only factor associated with therapeutic failure occurrence was severe chronic kidney disease (crude odds ratio 5.87; 95% CI 1.20, 28.69; p = 0.01). CONCLUSIONS: The TFQ was able to identify several cases of probable therapeutic failure leading to hospitalisation in frail, elderly patients. Non-adherence to effective therapies for chronic serious cardiopulmonary disease was a common cause of therapeutic failure and represents a target for interventions to reduce hospitalisation. Further research on the occurrence, risk factors for and types of therapeutic failure is needed in a larger cohort of older non-veterans.